Teacher Support- Kindergarten Referral Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.District *--- Select Choice ---Ash Grove R-IV School DistrictAurora R-VIII School DistrictAva R-I School DistrictAvilla R-XIII School DistrictBakersfield R-IV School DistrictBillings R-IV School DistrictBlue Eye R-V School DistrictBolivar R-I School DistrictBradleyville R-I School DistrictBranson R-IV School DistrictBronaugh R-VII School DistrictCarl Junction R-I School DistrictCarthage R-IX School DistrictCassville R-IV School DistrictChadwick R-I School DistrictClever R-V School DistrictCrane R-III School DistrictDadeville R-II School DistrictDallas County R-I School DistrictDiamond R-IV School DistrictDora R-III School DistrictEast Newton County R-VI School DistrictEl Dorado Springs R-II School DistrictExeter R-VI School DistrictFair Grove R-X School DistrictFair Play R-II School DistrictFordland R-III School DistrictForsyth R-III School DistrictGainesville School DistrictGalena R-II School DistrictGasconade C-IV School DistrictGolden City R-III School DistrictGreenfield R-IV School DistrictHalfway R-III School DistrictHartville R-II School DistrictHollister R-V School DistrictHumansville R-IV School DistrictHurley R-I School DistrictJasper County R-V School DistrictJoplin SchoolsKirbyville R-VI School DistrictLaclede County C-V School DistrictLaclede County R-I School DistrictLamar R-I School DistrictLebanon R-III School DistrictLiberal R-II School DistrictLockwood R-I School DistrictLogan-Rogersville R-VIII School DistrictLutie R-VI School DistrictManes R-V School DistrictMansfield R-IV School DistrictMarion C. Early R-V School DistrictMarionville R-IX School DistrictMark Twain R-VIII School DistrictMarshfield R-I School DistrictMcDonald County R-I School DistrictMiller R-II School DistrictMonett R-I School DistrictMount Vernon R-V School DistrictMountain Grove R-III School DistrictNeosho School DistrictNevada R-V School DistrictNiangua R-V School DistrictNixa Public SchoolsNortheast Vernon County R-I School DistrictNorwood R-I School DistrictOzark R-VI School DistrictPierce City R-VI School DistrictPlainview R-VIII School DistrictPleasant Hope R-VI School DistrictPurdy R-II School DistrictReeds Spring R-IV School DistrictRepublic R-III School DistrictSarcoxie R-II School DistrictSeneca R-VII School DistrictSheldon R-VIII School DistrictShell Knob 78 School DistrictSkyline R-II School DistrictSouthwest R-V School DistrictSparta R-III School DistrictSpokane R-VII School DistrictSpringfield R-XII School DistrictStockton R-1 School DistrictStrafford R-VI School DistrictTaneyville R-II School DistrictThornfield R-I School DistrictVerona R-VII School DistrictWalnut Grove R-V School DistrictWebb City R-VII School DistrictWestview C-VI School DistrictWheaton R-III School DistrictWillard R-II School DistrictGrade *KindergartenTeacher Name *FirstLastTeacher Email *Student Name *FirstLastAreas of Concern *Listening ComprehensionOral ExpressionMath CalculationReadingWritten ExpressionBehaviorStudent Currently Participates in the following servicesTitle ReadingTitle MathSpeech/Language TherapyMotor RTIIntervention GroupOtherLC-Can the student follow one-step verbal instructions accurately?YesNoSometimesLC- Does the student respond to simple yes or no questions during discussions?AlwaysSometimesRarelyLC-Does the student ask for help when they don't understand a simple request or instruction?AlwaysSometimesRarelyLC- How would you rate the student's ability to summarize information they've heard?ExcellentGoodFairPoorLC- Can the student retell a simple story or sequence of events from a storybook with support?YesNoSometimesOE- Does the student use complete sentences when speaking?AlwaysSometimesRarelyOE- Can the student express their needs or desires clearly using simple language?YesNoSometimesOE- How well does the student participate in simple conversations with peers?Very WellModerately WellNeeds improvementOE- Does the student demonstrate an understanding of basic vocabulary like colors, shapes, and common objects for their grade level?Yes, ConsistentlySometimesNo, RarelyMC- Can the student accurately count to current grade level expectations?YesNoSometimesMC- Does the student demonstrate the ability to match sets of objects to the corresponding number (i.e., 1 to 1 correspondence)?Yes, ConsistentlySometimesNo, RarelyMC- Can the student recognize number from 1 to 10Very WellModerately WellNeeds ImprovementMC- Can the student write numbers from 1 to 10?YesNoSometimesR- Can the student recognize and name all uppercase letters of the alphabet?YesNoSomeR- Can the student recognize and name all lowercase letters of the alphabet?YesNoSomeR- How well does the student demonstrate understanding of current phonemic awareness skills (segmenting words, identifying intial sounds, etc)?Very WellModerately WellNeeds ImprovementR- Can the student identify sounds associated with each uppercase letter?YesNoSometimesR- Can the student identify sounds associated with each lowercase letter?YesNoSometimesR- How fluent is the student in recognizing sight words at teh current grade level expectation?Very FluentModerately FluentNeeds ImprovementR- Does the student demonstrate comprehension of very simple texts or stories through pictures?YesNoSometimesW- Can the student write their first name independently?YesNoSometimesW- How well does the student use correct formation for uppercase letters?Very WellModerately WellNeeds ImprovementW- How well does the student use correct formation for lowercase letters?Very WellModerately WellNeeds ImprovementW- How well does the student use appropriate letter size and spacing in their writing?Very WellModerately WellNeeds ImprovementB- How often does the student exhibit disruptive behavior that interrupts the learning environment?Rarely (once a week or less)Occasionally (2-3 times a week)Frequently (daily or multiple times a day)B- How does the student respond to typical classroom behavior management strategies (e.g., verbal reminders, time-out, reward systems)?Positively (responds well and shows improvement)Inconsistently (sometimes responds, sometimes does not)Negatively (does not respond or behavior worsens)B- How does the student interact with peers during group activities or playtime?Appropriately (engages well and follows social norms)Inconsistently (sometimes interacts well, other times struggles)Inappropriately (often has conflicts or isolates themselves)B- To what extent does the student's behavior affect their academic performance?Minimal impact (rarely affects their ability to complete tasks)Moderate impact (occasionally affects task completion and focus)Significant impact (frequently prevents them from completing tasks and focusing)B- How often does the student require one-on-one attention from the teacher to manage their behavior?Rarely (can manage with minimal teacher intervention)Occasionally (needs teacher intervention 2-3 times a week)Frequently (requires constant or daily teacher intervention)Is there anything else the SIT team should know?File Uploads (Optional)Upload Any Relevant Student Files or Artifacts #1 Drag & Drop Files, Choose Files to Upload Support file types, including documents (.doc, .pdf), and images (.jpg, .png)Upload Any Relevant Student Files or Artifacts #2 Drag & Drop Files, Choose Files to Upload Support file types, including documents (.doc, .pdf), and images (.jpg, .png)Upload Any Relevant Student Files or Artifacts #3 Drag & Drop Files, Choose Files to Upload Support file types, including documents (.doc, .pdf), and images (.jpg, .png)Send
